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Lumbar Neuraxial Ultrasound for Spinal and Epidural Anesthesia a Systematic Review and Meta-Analysis

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Lumbar Neuraxial Ultrasound for Spinal and Epidural Anesthesia a Systematic Review and Meta-Analysis SPECIAL ARTICLE Lumbar Neuraxial Ultrasound for Spinal and Epidural Anesthesia A Systematic Review and Meta-Analysis Anahi Perlas, MD, FRCPC,*† Luis E. Chaparro, MD,‡ and Ki Jinn Chin, MD, FRCPC*† pinal anesthesia and lumbar epidural anesthesia are commonly Background: This systematic review examines the evidence for prepro- Sperformed anesthetic and/or analgesic techniques with a long cedural neuraxial ultrasound as an adjunct to lumbar spinal and epidural track record of efficacy and safety. However, neuraxial blocks anesthesia in adults. can occasionally be challenging to perform, particularly if the Methods: We searched MEDLINE, EMBASE, and Cochrane Central spinal anatomy is altered or obscured by factors such as obesity, Register of Controlled Trials databases from inception to June 30, 2014, spinal deformities, or previous spine surgery.1 Technical difficulty for randomized controlled trials (RCTs) and cohort studies that reported can result in procedural failure, suboptimal epidural analgesia, data answering one or more of the following 3 questions: (1) Does ultra- and increased needle trauma. It may also increase the risk of both ound accurately identify a given lumbar intervertebral space? (2) Does minor complications such as postdural puncture headache and ultrasound accurately predict the needle insertion depth required to reach backache and major complications including epidural hematoma the epidural or intrathecal space? (3) Does ultrasound improve the effi- and spinal cord injury.2–4 cacy and safety of spinal or lumbar epidural anesthesia? Neuraxial ultrasound is a recent development in the field of Results: Thirty-one clinical trials and 1 meta-analysis were included in regional anesthesia. A “pre-procedural” ultrasound examination this review. Data from 8 studies indicate that neuraxial ultrasound can iden- of the spine accurately delineates the underlying relevant anatomy, tify a given lumbar intervertebral space more accurately than by landmark thus aiding in successful insertion of a spinal or epidural needle; palpation alone. Thirteen studies reported an excellent correlation between this has also been termed “ultrasound-assisted ” neuraxial blockade. ultrasound-measured depth and needle insertion depth to the epidural or Although real-time ultrasound-guided spinal and epidural intrathecal space. The mean difference between the 2 measurements was techniques have been described, they are distinctly different from within 3 mm in most studies. Thirteen RCTs, 5 cohort studies, and 1 meta- the ultrasound-assisted approach. They remain experimental at analysis reported data on efficacy and safety outcomes. Results consistently this time and will not be discussed in this review. showed that ultrasound resulted in increased success and ease of per- The objective of this review was to examine the evidence formance. Ultrasound seemed to reduce the risk of traumatic procedures supporting the use of preprocedural neuraxial ultrasound to but there was otherwise insufficient evidence to conclude if it significantly facilitate spinal or lumbar epidural anesthesia and, based on improves safety. this, to set forth recommendations for practice. We addressed Conclusions: There is significant evidence supporting the role of neur- 3 distinct clinical questions: axial ultrasound in improving the precision and efficacy of neuraxial anesthetic techniques. 1) Does neuraxial ultrasound accurately identify a given lumbar What's New: We know that neuraxial ultrasound is a useful complement to clinical examination when performing lumbar central intervertebral space? 2) Does neuraxial ultrasound accurately predict the needle neuraxial blocks. It provides anatomical information including the depth of the epidural space, the identity of a given intervertebral level, and the insertion depth required to reach the epidural or intrathecal location of the midline and interspinous/interlaminar spaces. This infor- space? mation can be used to successfully guide subsequent needle insertion. 3) Does neuraxial ultrasound improve the efficacy and safety of spinal or epidural anesthesia? Since 2010, new data from RCTs and 1 meta-analysis suggest that neuraxial ultrasound increases the success and reduces the technical difficulty of lumbar central neuraxial blocks. Findings from the meta- analysis suggest that neuraxial ultrasound reduces the risk of traumatic METHODS procedures, and thus may possibly contribute to the safety of lumbar For this review, we included all randomized controlled trials central neuraxial blocks. (RCTs) and cohort studies involving neuraxial ultrasound and (Reg Anesth Pain Med 2016;41: 251–260) spinal or lumbar epidural anesthesia/analgesia in adult patients. We also included studies involving diagnostic lumbar puncture, given that the needle insertion technique is identical to that of From the *Department of Anesthesia and Pain Management, Toronto Western spinal anesthesia. We excluded studies of real-time ultrasound- Hospital, University Health Network; †Department of Anesthesia, University guided neuraxial blocks as well as those related to interventional of Toronto, Toronto, Ontario, Canada; and ‡Department of Anesthesiology, Hospital Pablo Tobón Uribe, Medellín, Colombia. pain procedures on the spine. Studies that did not report outcomes Accepted for publication October 10, 2014. related to the 3 primary questions were excluded. We performed Address correspondence to: Anahi Perlas, MD, FRCPC, University of Toronto, a literature search of the MEDLINE, EMBASE, and Cochrane Mc Laughlin Pavilion 2-405, 399 Bathurst St, Toronto, Ontario, Canada Central Register of Controlled Trials databases from the time of M5T 2S8 (e‐mail: [email protected]). The authors declare no conflict of interest. inception until June 30, 2014. The following search terms were Drs Anahi Perlas and Ki Jinn Chin received academic time support through a used: ultrasound, ultrasonography, epidural, peridural, subarachnoid Research Merit Award 2011–2013 and 2013–2015, respectively, from the space, epidural analgesia, epidural anesthesia, spinal anesthesia, and Department of Anesthesia, University of Toronto. conduction anesthesia. No language restrictions were applied. The Copyright © 2014 by American Society of Regional Anesthesia and Pain Medicine abstracts of all references identified by the search were independently ISSN: 1098-7339 reviewed by 2 authors. Full text copies of potentially relevant DOI: 10.1097/AAP.0000000000000184 studies were obtained and again underwent independent review Regional Anesthesia and Pain Medicine • Volume 41, Number 2, March-April 2016 251 Copyright © 2016 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited. Perlas et al Regional Anesthesia and Pain Medicine • Volume 41, Number 2, March-April 2016 by 2 authors. Data from studies that met the inclusion criteria RESULTS were entered into a standardized data extraction form. All dis- Seven hundred six citations were identified in the initial agreements were resolved by discussion and mutual consensus search of which 57 were selected as potentially relevant and among the 3 authors of this review. We performed a risk of bias 5 underwent full-text review (Fig. 1). Of these, we excluded 25 studies assessment for each study. The QUADAS-2 tool was used for for the following reasons: 9 were narrative reviews or descrip- studies of diagnostic accuracy of neuraxial ultrasound in tive articles, 6 were in the pediatric population, 6 involved in- identifying lumbar intervertebral spaces. We used the Jadad terventions on the thoracic or cervical spine, and 4 were case score6 and the Cochrane Collaboration's risk of bias assessment 7 reports. One meta-analysis was identified and included in this tool for RCTs looking at the effect of neuraxial ultrasound on review.10 clinical outcomes.7 We performed meta-analysis using RevMan 5.3 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, 2014). The treatment effect was expressed as risk Does Neuraxial Ultrasound Accurately Identify a ratio for dichotomous outcomes and as mean difference (MD) Given Lumbar Interspace? for continuous data outcomes, respectively, along with 95% Eight studies11–18 involving a total of 624 patients addressed confidence intervals (CIs). Statistical heterogeneity was assessed this question (Table 1). All 8 studies used a “counting-up” approach using both the χ2 test and I2. The studies that reported on the in which the ultrasound probe was placed in a longitudinal orien- correlation of the ultrasound-determined depth of the epidural tation over the sacrum (identified as a continuous hyperechoic line) or intrathecal space versus needle insertion depth under- and then moved cephalad to identify successive spinous pro- went meta-analysis using R software (version 2.15.3). Fisher cesses or laminae and the corresponding interspinous or inter- z-transformation was applied to the Pearson product moment laminar spaces.19 A low-frequency curved-array probe was used correlation coefficients before meta-analysis. The final results in all studies except one.16 These 7 studies were generally of good of pooled z scores were back-transformed to the pooled correlation quality according to the QUADAS-risk of bias assessment tool coefficients. for diagnostic studies, with only 2 studies receiving a “high” Summary recommendations follow the format suggested rating in one domain each. Five studies examined the agree- by the US Department of Health and
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